The challenges of staffing the Affordable Care Act in Southwestern New Mexico
by Cindy Donatelli
The Affordable Care Act, more familiarly known as Obamacare, is just about to kick into high gear, as crucial parts of the legislation become effective in the next few months. On Oct. 1, 2013, the Healthcare Exchanges will be open for business — Expedia-like websites that will allow people to sign up for health insurance offered online. There will also be personal and phone-in support to ensure that everyone is able to register, even if you do not have access to a computer.
In New Mexico, currently 415,000 people lack any kind of health insurance. It is projected that by 2014, up to 172,000 of the state's uninsured population will receive coverage either through Medicaid expansion or through participation in the health insurance exchanges. The latter will offer subsidies to those who earn between 133% and 400% of the poverty level (as established by the US government) to make health insurance more affordable.
On Jan. 1, 2014, all US citizens will be required to have health insurance, or face fines. Pre-existing conditions will no longer determine who qualifies for coverage, and health insurers, by law, will have to offer certain set standards of care.
It is obvious that this is going to create huge changes in healthcare delivery. Changes in the implementation dates for certain key provisions of the act have been in the news just recently, an indication that we are all still in flux with all these changes just a few months away.
But here, I want to consider not the implementation of the act itself, but the consequences for patient care here in New Mexico, in both the short and long term. In a state already underserved by healthcare practitioners, new patients who enter the system in 2014 will create a wave of demand for healthcare that almost certainly cannot be met by the status quo. There is no question that we will need more primary care practitioners, as well as nurses. A report by the Department of Health submitted to the Legislative Finance Committee in May 2013 declares: "In the near-term, the lack of supply will result in longer wait times to see a provider and more difficulty accessing specialists."
On top of that, New Mexico's population is graying: By 2030, New Mexico will rank fourth in the nation in the proportion of the population over age 65. Since older individuals are more likely to be heavy users of healthcare, it will be an even greater challenge to provide adequate healthcare delivery given the demographic projections in the state.
So how will we increase our capacity for health delivery to meet these challenges, especially when 13.5% of physicians in New Mexico "report they plan to retire or to significantly reduce their patient care hours," according to the Department of Health? First of all, we must recognize that the entire population does not require the same level of care. There will be changes in healthcare delivery. An effort is underway to coordinate the care of patients with multiple chronic illnesses by establishing "medical homes." Relatively healthy patients will require low levels of care with more emphasis on preventative approaches. But even if we achieve greater efficiency and economy in healthcare delivery, we will still need new practitioners to meet the increased demand.
Michael Harris, FNP-C at Silver Health CARE, part of the “mid-level” solution to healthcare staffing challenges.
According to the Department of Health's report, the answer seems to demand that "mid-levels" — nurse practitioners and physician assistants — play a greater role in primary care. While nurse practitioners currently practice independently without restrictions on their license, physician assistants, while they may see patients on their own, must practice under the supervision of a physician. For example, Silver Health CARE is able to provide improved access to both primary care and urgent care because it has three nurse practitioners and six physician assistants on staff, who see and treat a considerable number of patients.
Indeed, a recent survey reported that patients are more willing to be seen by mid-levels, especially when there was a long wait time to see a physician or when they have already been treated by a mid-level. The key role of the mid-level in healthcare is still not entirely clear to the public because of greater prominence accorded historically to the role that doctors play in the medical system. More mid-level primary care providers will keep people healthy by monitoring emerging medical problems before they become chronic or life-threatening.
Yet while the legislative report recognizes that mid-levels would provide the healthcare delivery necessary for the new patient population, the report also recognizes that New Mexico does not have enough training programs to increase this mid-level labor force quickly enough. Recruitment from other states will no doubt prove difficult since the needs for mid-levels are just as great elsewhere in the country.
The unequal distribution of the healthcare workforce in New Mexico exacerbates the problem in rural areas like Grant County. Southwestern New Mexico has 10% of the doctors in the state, compared to Bernalillo County, where 41% of the state's physicians practice. The report concludes by proposing an increase in the number of training programs for mid-levels in New Mexico. Economically, mid-levels cost much less to educate; training costs are estimated at 20-25% the cost of a physician. The report also suggests revisiting the requirement that physician assistants work under the supervision of an MD by granting them the same independence as nurse practitioners once they have been supervised clinically for three to five years.
While southwestern New Mexico will face challenges as a rural area, we begin with an inherent advantage in having two well-established, successful clinics to treat patients in Grant, Luna, Hidalgo and Grant counties, as well as the Gila Regional Medical Center. Silver Health CARE, established in 1975, is now in its 39th year of continuous operation. It began as a practice of two physicians, Dr. John Bell and Dr. Samuel D. Dye, who were later joined by Dr. James Skee in 1981. Over the years, the clinic has expanded dramatically to improve accessibility for all patients in the area.
In addition to the main clinic and The Family Clinic in Silver City, clinics have been opened in Deming and Bayard. Urgent Care Clinics for walk-ins in Deming and Silver City provide an affordable alternative to the emergency room for minor illnesses and injuries. Urgent Care was set up to give patients access to care without an appointment; by being open weekends and evenings, it gives patients an option when other offices may be closed.
Hidalgo Medical Services is the other well-established medical clinic for patients in these counties. HMS originally received state and federal funds to meet the medical needs of Hidalgo County, but its services and clinic locations have expanded dramatically over the past 18 years. Originally established in a trailer behind the hospital in 1995, HMS currently operates seven clinics in Hidalgo and Grant Counties, and celebrated the opening of the impressive HMS Silver City Community Health Center in February 2013, which offers primary care, dental and behavioral healthcare, and family support services at one site.
Both clinics have shown themselves to be proactive in adapting to change, and that bodes well for the expansion of quality healthcare for the patients of southwestern New Mexico, even with the upcoming challenges of the Affordable Care Act. HMS has used its promotoras to promote health education and preventative care among marginalized and vulnerable communities, and to offer other patient-oriented services. HMS's sliding scale has allowed the extension of healthcare to those who can least afford it, a precursor to one of the main goals of the expansion of Medicaid under the ACA. Most recently, HMS has established a Family Practice Residency program, which is intended to bring in doctors who might decide to settle in our communities to provide primary care.
Silver Health CARE, in addition to its physical expansion into more communities, has been a cutting-edge innovator in healthcare delivery. Silver Health CARE has been acknowledged as the state leader in the introduction of electronic medical records; the clinic switched over to electronic records in 2001, thereby anticipating one of the goals of the ACA. With a Clinical Laboratory Improvement Amendments (CLIA)-certified lab onsite, Silver Health CARE is able to provide patients with faster and more convenient results at an affordable cost. A secure patient portal, WebView, allows patients to view their medical records online, and plans are underway to expand the communicative capacities of these portals between practitioner and patient.
There have also been very successful collaborations between Hidalgo Medical Services and Silver Health CARE that have as their goal improved health education and access. The Medication Assistance Program was developed by Silver Heath CARE and was later shared by both clinics. It continues to offer counseling at both sites to help those who have difficulty purchasing prescribed drugs, assisting them in determining which among the myriad plans best meets their needs. Health fairs and other educational events have been joint efforts as well, where the two clinics have cooperated along with other health-related organizations in our county.
While the implementation of the Affordable Care Act is going to be a bumpy ride for all over the next few months, we can perhaps all agree that the goal of the act, to provide access to healthcare for as many as possible, is laudable. We in Southwestern New Mexico can be encouraged that we have well-established and innovative healthcare organizations in place to make the changes necessary to adapt to the increased patient demand for medical services.
For appointments, call (575) 538-298 in Silver City and (575) 544-4422 in Deming.
Cindy Donatelli is in charge of advertising,
marketing and public relations at Silver Health CARE.
Body, Mind & Spirit is a forum for sharing ideas and experiences on all aspects of physical, mental and spiritual health and on how these intersect. Readers, especially those with expertise in one or more of these disciplines, are invited to contribute and to respond. Write PO Box 191, Silver City, NM 88062, fax 534-4134 or email firstname.lastname@example.org.
The opinions expressed herein do not necessarily reflect the views of Desert Exposure or its advertisers, and are not intended to offer specific or prescriptive medical advice. You should always consult your own health professional before adopting any treatment or beginning any new regimen.